Defensive Medicine is a Symptom, not a Disease

10 min read


We are living through an increasingly litigious ecosphere. Patients expect better from their physicians, demand more from their administrations, and, most of all, rely extensively on their consumeristic predispositions. Consequently, governments raise the bar on quality and vigilance through indiscriminate clerical mandates and bureaucracy. The excessive dictates- which in turn places an extra burden on the medical community, predominantly physicians. The concluding scenario stays a vicious circle of petition, mandate, and accountability. If the cycle not corrected, it would potentially cause the physician to burnout, change profession, or take up a defensive medical practice. Whichever footpath a physician takes is not healthy for the medical. Metaphorically speaking, altogether, the above three scenarios conveys its own individual “can of worms.” Here within, I would like to discuss lone the topic of “Defensive Medicine.”

What is Defensive Medicine?

Defensive medicine refers to the type of medical practice preordained to avert the likelihood of pending malpractice litigations. Physicians taking up defensive medicine merely responds wanting to evade liability, in contrast, to benefiting patient. Latter may take in but not restricted to ordering tests, procedures, or scheduling multiple visits. The practice of defensive medicine is one of the most undesired side effects of growing medical lawsuits. It raises healthcare costs and exposes patients to avoidable perils.

The defensive medicine practice remains not necessarily for the best benefit of the patient, even though it may seem to the patient as a positive move. A defending medical exercise tends to simply aim at shielding the practitioner against the patient who may be a potential plaintiff.

Types of Defensive Medicine

In general, defensive medicine can be categorized into two unique behavioral ways; “Assurance behavior” and “Avoidance behavior.”

Assurance behavior affects the ordering of additional yet redundant services for a variety of reasons. The said behavior is typically aimed to lessen unfavorable consequences, preventing patients from filing medical malpractice suits, or appropriate future legal action utilizing recording that the physician is, in fact, practicing bestowing to the standard of care.

Avoidance behavior, on the other hand, ensues when physicians decline to engage in high-risk measures or circumstances.

Rate of Defensive Medicine

The defensive medicine rate in the United States of America, remains as high as 79% to 93%, predominantly in emergency medicine, obstetrics, and some other high-risk specialties.

Because the art of medicine encompasses ocean of unpredictability. Henceforth inescapably, every clinician in their particular lifetime has contemplated in one form or another to exercise defensive medicine. The after-mentioned turn out to be even more manifest as the government’s role in healthcare delivery grows spacious, and patients have more access to information.

U.S. physicians are at the highest chance of being sued; hence overtreatment is common in this country. The number of lawsuits against doctors in the United States has grown during the last decades, exerting considerable comportment on physician deeds and their practice. The numeral of Physicians ordering excessive tests or dodge high-risk patient treatment to reduce exposure to grievances continues to increase. More than ever, Medical doctors bring an end to their practice because of exorbitant insurance premiums.


Possible causes of Defensive Medicine

Defensive medicine is a reaction to the intention to take legal actions as well as rising costs of malpractice insurance premiums. Patients’ inclinations on litigating may be for deferred diagnosis or treatment but usually not for being over-diagnosed.

Even the Healthcare reform, including the Affordable Care Act (ACA), has failed to improve the efficiency of health care delivery by missing to recognize the powerful motivation that liability qualms hold on physician practices.

The medical malpractice system, often unkempt in the healthcare dialogue, is deceptively due to the credence by the collective that liability has more to do with inadequacies in physician-patient communication than it does with the overall level of expenditure elected by physicians. The end may hold some truth, but the emphasis; the disparity between the patient expectation, insurance carrier reimbursement practice, and tunnel vision of the legislatures is, in fact, a prominent source of insufficiency between physicians and patient communication.

Being sued may not be unswervingly about whether physician orders countless or few tests. Barring the multifacetedness of the burden on physicians may force them to select the self-protective route as a shortcut remedy.

Indeed, bedside manner and how well doctors interact with patients can reduce malpractice litigation. However, the clinician who finds themselves on the verge of burnout while taking care of a strong-opinionated patient in the company of limited means will probably wield extra discretion to prevent legal action.

Photo by Rohan Makhecha on Unsplash

Interpersonal factors undoubtedly influence liability risk; still, the vast majority of U.S. physicians practice defensive medicine is reminiscent of spending has a role to play in lessening liability risk, or at least that does in physicians independent cognizance.

A study published by the British Medical Journal unveils that physicians with higher expenses in a given year were considerably less likely to be sued for malpractice. Midst obstetricians, for whom C-sections often considered to be defensively inspired, directs that doctors with higher C-section rates faced fewer law suites than their conservative counterparts.

Consequences of Defensive Medicine

Defensive medical practice and higher spending, accordingly, seems to reduce the likelihood of adverse outcomes. The higher disbursement may similarly prompt patients, judges, and juries; despite wrongdoing, the doctor stayed exhaustive in his or her workup and treatment. In either setup, the ground for physicians to lessen healthcare spending is dramatically benumbed by the feasibility that their susceptibility to lawsuits may grow if they do so.

Defensive medicine is a prominent patron to the rise of healthcare costs in the United States. By estimation, defensive medicine adds $25.6 billion or 34% to already rising healthcare expenditure annually.

Overtreatment with antibiotics is a well-recognized mark of defensive medicine. It threatens everyone, as bacterial resistances such as Methicillin-resistant Staphylococcus aureus (MRSA) can develop, causing untreatable infections in countless patients. Or Appropriate medical treatments such as watch-and-wait for some low risk, slow-growing prostate cancers may not be practiced because patients demand belligerent therapy options such as radical prostatectomy, radiation, or hormone therapy.

A study, conducted by authors from Harvard University and the University of Melbourne, estimated that defensive medicine cost Americans $45.6 billion annually in 2008 dollars, accounting for more than 80% overall yearly incidentals of the medical liability practice.

According to the study, defensive medicine costs $38.8 billion and $6.8 billion for hospitals and physicians, respectively. To solve this dilemma, researchers accept it as accurate that Congress can address this issue through tort reform; however, despite the failed past attempts.

Insight in Defensive Medicine

The row against including malpractice transformation or attempting to reform healthcare, focusing on lower spending, is typical of the attitude that the malpractice system is exceedingly trivial to be the cause of increasing healthcare expenditure. Unmindful of whether or not this holds valid, the relationship between spending and liability risk indeed suggests that the malpractice scheme as it currently stands is a letdown.

The efficacy of value-based reimbursement and delivery arrangement standards to enhance the efficiency of healthcare distribution and reduce spending will undoubtedly depend on a particular perception by treating physicians.

Further bureaucratic amelioration such as implementing patched of safe harbors, disclosure-and-offer plans, and no-apology laws will not solve the defensive medicine until the malpractice improvements break the link between physician spending and the likelihood of being queried.

According to research presented in the New England Medical Journal, three states of Texas, Georgia, and South Carolina passed an enactment that distorted the malpractice standard for emergency care to gross negligence. The study suggests that there was no decline in the prevalence of CT or MRI utilization or hospital admission in any of the altered states post-enactment, and no modification in charges distinguished in Texas or South Carolina. In Georgia, however, restructuring was associated with a 3.6% reduction in per-visit emergency department charges. The study proposed that the Legislation that switched the malpractice standard for emergency physicians in focus states had tiny upshot on the intensity of medical practice.

Some believe that across all specialties, reducing medical malpractice premiums would reduce costs by 2%. It is also a belief that the magnitude of appreciated savings is insignificant, accounting for no more than 1% of medical care costs in a piece specialty. Across all thirty-five specialties, savings associated with a 10% premium reduction in medical malpractice premiums would be just 0.132%. Even if we can reduce medical malpractice premiums by as much as 30%, defensive medicine costs will decline no more than 0.4%.

Business-centered health care or patient-centered business

How to reduce Defensive Medicine

Few scholars believe that the menace of a malpractice claim has created an incentive for physicians to imitate the practices commonly habited by other colleagues, regardless of whether those treatment decisions are consistent with what clinical evidence deems necessary. Hence to overcome, they have Proposed to place a limit on the latter type of damage awards to lower healthcare expenses. The after-mentioned types of reform proposals don’t seem to take into account the practice variations and disparity of the treatment plan that comes with individual clinical judgment. Instead, the safe-harbor method suggested in this brief inspires physicians to follow rigid evidence-based guidelines, which will enhance the medical quality of care and patient safety. Nevertheless, the extreme application of guidelines by itself remains as an independent theme of controversy.

An article published in World J Clin Cases in 2018 views the growth of defensive medicine in the context of broader shifts towards the understanding of medicine that have occurred in the last several decades. The study sees the recent change as the main factor in undermining the patient-physician trust, something that has traditionally been the primary source of professional satisfaction for doctors. These changes include factors such as patient visits time overhauled by the time dedicated to reviewing electronic health records (#EHR) and paperwork. It postulates further; family physicians are playing an even lesser central role in the care of patients, and extreme guidelines and algorithms are replacing the art of clinical reasoning.

The patients and young physicians of our era trust that medicine is another perfect science rather than an imperfect art. As an upshot, modern societies are losing tolerance to the inevitable morbidity and mortality.

To ultimately demote the increasing defensive behavior of doctors around the world, even the decriminalization of medical errors and the assurance that they can be dealt with in civil courts or by medical organizations may help but not adequately.

It is vital that physicians and surgeons have the opportunity to spend enough time with their patients and should give clinical reasoning the attention it merits.

The institutions should support the doctors who have experiences in adverse patient events, and the media must also stop reporting with excessive evidence false claimed medical errors which subject physicians to premature public judgment before being concluded in the court of law.

A three-step approach to Defensive Medicine and Cost relating Lawsuits

The solution for saving $650-$850 billion per year lawsuit-driven healthcare spending cost requires three steps approach was the subject of some of the most recent advocacies. The method is supposed to initially eliminate personal fiscal accountability for physicians’ unintended erroneousness, so they can treat patients for what’s needed, not out of fear of a lawsuit. The scheme likewise involves creating independent, expert medical review boards to evaluate every claim and determine if negligent conduct; rendered to the patient. Finally necessitates establishing independent committees to award consistent, fair settlement to wrongfully injured patients.

The three-step approach is prevalent, nonetheless, functions in a setting where physicians are not practicing independently. The scheme creates an unhealthy environment for bureaucracy, monopoly, and favoritism, further adding to the physician burden.

Malpractice Reform key to diminishing expenses of Defensive Medicine

It is the predominant backing that adherence to evidence-based clinical-practice guidelines is the key; however, the crucial is to employ “qualified” health information technology systems, even though it is hard to figure out what genuinely signifies the parameters for the qualification.

The plan seems to be over-reliant on technology, which includes clinical decision-support systems that incorporate guidelines to support them with patient diagnoses and treatment options, thus placing the physicians on the path for further utilizing standardized clinical decision making.

Furthermore, the Center suggests patients who bring malpractice claims must show; their physicians failed to meet the standard of care while treating their specific conditions. Under this safe harbor, a guiding principle would define the legal standard of care. Patients could still present evidence that the “guidelines” didn’t apply to their circumstances or that their physicians did not follow the instructions.

Single-Payer and Defensive Medicine

Proponents of a single-payer system contend that government-sponsored insurance would potentially save money by lessening administrative expenses, even though, conferring to few scholars, the relations of regulatory payments between private and government-run insurance programs remain ambiguous. It has proposed that organizational costs are only a small slice of healthcare costs in the United States. The first problem downplayed time and again, is the overuse of healthcare, particularly of the expensive new technologies and drugs.

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A single-payer system will subject physicians to unwanted and unnecessary oversight by the government in healthcare decisions. Consequently, With the newfound power to benchmark physicians and regulate payments, the government will inevitably restrain the usage of maybe beneficial therapies and reimburse differentially for perceived variations in quality. The after-mentioned carries potentially unintended consequences such as increased healthcare inequalities and hence exacerbating the already awkward avoidance form of defensive medicine.

We are focusing on the wrong reason and the wrong solution

Defensive medicine is a real problem, as is the apparent sign of significant snap within the healthcare system. Undoubtedly protective medical practice is not only damaging to the already escalating healthcare costs, more so is counterproductive to quality medical practice, value-based service reimbursement, and, most of all, patient satisfaction. Inadequate strategy to break the vicious circle of increasing mandates, tort reform, and unjustifiable cost control will eventually add to the already soaring physician burnout and patient dissatisfaction.

Based on altogether reviews I have enclosed in this article, the majority of the emphases are on cost analysis and reduction. The mainstream argument is whether reforming tort, tightening the choker on the lawsuit will save money. So far, we cannot find a discussion around the doctor-patient relationship, resorting to personalized medical practice, and reducing corporate influence in the practice of medicine.

Photo by Bill Oxford on Unsplash

It is utterly apparent that corporations, be it the insurance industry, pharma, medical device, legal industry, or HITEC would enjoy certain physician practices to intensify their financial return. Therefore, one can hardly see the incentive for the corporate cartel to collectively try to promote the fundamental mission of every healthcare system; that is, doctor-patient interaction.

Defensive Medicine is a symptom, not a Cause

Assurance and Avoidance in defensive medicine pertain to human behaviors and stand for particular signs pointing to significant flaws in the system. They represent the symptom of patient distrust, physician fatigue, and insecurity. Tort reform, single-payer strategy, placing a cap on legal claims, and even standardization of medical practice metaphorically resembles prescribing Acetaminophen for high fever without addressing the disease itself.

Indeed, We are experiencing the utter semantic shift as to what defines a correct medical practice. Social engineering is continually prompting attitudes and behaviors on a large-scale medical solution. The end has forced the replacement of clinical judgment with one-size-fits-all guidelines that are typically dictated by administrative and corporate bureaucracy. Extreme, inflexible application of Protocols, Standard Operating Procedures are off-putting the already fraught medical Practices.

Medical Practice is losing its Personal touch

Clinical medicine has always been about patient-physician trust, and this has traditionally been by far the primary source of professional gratification for physicians as well as the patients. Indeed, factors such as the kudos of medicine, intellectual encouragement, interaction with colleagues, and financial rewards are much less critical. Unfortunately, the fundamentals of patient trust have been with time eroded by a lack of patient face-time, increasing scarcity of clinical autonomy, and liability worries.

A National Survey of America’s Physicians indicates that only 14% of physicians have the needed time to provide the highest levels of care, as 60% have been detracted from patient interaction through the use of poorly validated electronic health records. 54% of practicing physicians have negative confidence, 49% grieve from feelings of burnout, 49% wouldn’t recommend medicine as a profession to their children. Up to 48% intend to reduce hours, retire, get a non-clinical job, or limit patient access to their practices. Only 37% have positive feelings about the forthcoming of the medical profession. The trend is not a picture merely limited to one country. On the contrary, these feelings; increasingly shared by doctors in many other countries.

Medical societies, too, are failing the physicians, and government solutions are shallow.

To implement an effective system of healthcare, one must be able to formulate justifiable logistics. The kind of stature by which individual desires are addressed. Still, hard to achieve, given the circumstances. The latter, orderly, serves as a prerequisite to establishing medical care protocols that respect such necessity, thus “Rugged individualism.”

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Adam Tabriz, MD Dr. Adam Tabriz is an Executive level physician, writer, personalized healthcare system advocate, and entrepreneur with 15+ years of success performing surgery, treating patients, and creating innovative solutions for independent healthcare providers. He provides critically needed remote care access to underserved populations in the Healthcare Beyond Borders initiative. His mission is to create a highly effective business model that alleviates the economic and legislative burden of independent practitioners, empowers patients, and creates ease of access to medical services for everyone. He believes in Achieving performance excellence by leveraging medical expertise and modern-day technology.

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